PRE-INSPECTION QUESTIONNAIRE INSTRUCTIONS Submit copies of all documents or records outlined below. If you do not have the required information, indicate whether or not you expect to have it at the time of the site inspection. This information will be included in the final score by which your accreditation status is determined. Fill in all blanks on pre-questionnaire charts. If you are unable to answer any questions, indicate you will have the information available at the time of inspection or give reason(s) you consider the information requested to be not applicable to your eye bank's operations. The information submitted in this Pre-Inspection Questionnaire shall reflect all agencies, services, certifications, etc. utilized since the date of your eye bank s last EBAA inspection. If you do not understand the questions, please contact your Lead Inspector or the Chair(s) of the Accreditation Board. QUESTIONNAIRE 1. Please provide the following information for all agencies with which the eye bank contracts services or if the eye bank performs the activities itself, e.g., serology, sterilization, microbiology, etc. Documentation provided for accreditation / certification (CLIA/FDA/EBAA) must cover each year the agency was used by the eye bank since the date of the eye bank s last inspection. D1.200 1-A. SEROLOGY: Please provide the requested information in the attached chart labeled QUESTION #1-A. C3.300, C3.510, 1-B. ALL OTHER SERVICES: Please provide the requested C3.700 information in the attached chart labeled QUESTION #1-B. C1.300, C2.000 1-C. RECOVERY, PRESERVATION, AND/OR PROCESSING SERVICES: Please provide the requested information in the attached chart labeled QUESTION #1-C. EBAA Accreditation Board, Pre-inspection Questionnare June 2016 Page 1 of 4
2. Please provide the following: C1.100-C1.300 2. STAFF: Please provide the requested information for individuals performing the identified functions in the attached chart labeled QUESTION #2. 3. Please provide the following information: C1.200 3-A. Name of Medical Director C1.200 3-B. If Medical Director has not completed a corneal fellowship, or does not have demonstrated expertise in corneal surgery, document a consulting relationship with an ophthalmologist who has completed a corneal fellowship. C1.200 3-C. Name and qualifications of back-up Medical Director. C1.300 3-D. If the Medical Director fulfills the role of CEBT in a supervisory position, provide documentation of current certification. 4. Please submit the following documentation: C1.200 4-A. A copy of the Medical Director s certificate of attendance at the Medical Directors Symposium of an EBAA Annual Meeting at least once every three (3) years and a Medical Advisory Board meeting once every three years in the time period preceding this scheduled site inspection. C1.300 4-B. Copy/copies of the certification/recertification of the eye bank s CEBT in a supervisory role covering the three (3) years preceding this scheduled site inspection. B1.000 4-C. A copy of the eye bank s annual FDA registration for each year since the last inspection. B1.000 4-D. If the state regulates eye banking, a copy of the inspection certificate or letter for each year since the last inspection. C3.200 4-E. A copy of annual certification for Processing Environment(s), as well as certification following any move of a Laminar Flow Hood, for each year since the last inspection. J1.000 4-F. A sample of a completed label used for each type of tissue distributed by the eye bank (e.g., corneoscleral disc, sclera or whole eye for surgery and/or research or training use). B1.000 4-G. Documentation of registration with ICCBBA for FIN. EBAA Accreditation Board, Pre-inspection Questionnare June 2016 Page 2 of 4
5. Describe, in one page or less: J1.000 5. The system used by your eye bank to assign donor and tissue numbers (i.e., identification system). Provide sufficient detail that inspectors can make a preliminary determination of records to be selected for review during the site visit. Include any samples that you think would help the inspectors to understand your system. 6. Using the following donor profile, D1.200 6. Complete your eye bank s plasma dilution worksheet or explain how you would apply your eye bank s plasma dilution algorithm to determine whether or not a pre-transfused specimen is required. Indicate what (if any) additional information you would seek in order to make the determination. DONOR PROFILE: Upon reviewing all medical records available, you find the following information: EMS was called to a residence for a 75 y/o individual (weighing 60 Kg.) c/o chest pain. Upon arrival at 1055, patient was found to be in CPA. ACLS was started, along with an IO line (250 cc bag of Normal Saline) established to the right lower leg at 1057 infusing at wide-open rate. After approximately 3 minutes of CPR, a weak heartbeat was regained. The patient was transported to a local ER. Upon arrival to the ER, at 1120, a peripheral line was established with a liter bag of Lactated Ringers infusing at wide-open rate. No blood sample was drawn in the ER upon arrival, or by EMS prior to arrival. After emergent evaluation, the patient was taken to the cath lab at 1137, where a 2 nd peripheral line was established, at 1140, with a liter bag of Lactated Ringers infusing at 200 cc per hour. At 1139, the peripheral IV started in the ER upon arrival infiltrated and access was lost. The cath lab procedure started at 1150. At approximately 1205, one of the cardiac vessels was ruptured and 2 units of PRBC were ordered to be given with a rapid infuser. The 2 units of PRBC, via rapid infuser, were begun at 1208. The OR was alerted that the patient was being brought to the OR for an emergent bypass. At 1210, the patient went into CPA and ACLS was begun. The patient arrived in the OR suite at 1213, with ACLS in progress. During the surgical prep of the patient, the surgeon decided to end resuscitation and the patient was pronounced dead at 1218. Calculate fluid status using your eye bank's plasma dilution worksheet /algorithm and specify whether the post-mortem sample is sufficient for infectious disease testing. A copy of the worksheet or the calculations performed to determine fluid status must be included. M1.300-M1.500 7. Please attach a copy of each form used by the eye bank to record donor and recipient information. Be sure to include any forms that are filed in your donor/recipient records, such as screening forms, checklists, body inspection forms, autopsy forms, slit lamp and tissue report forms and recipient follow-up forms, as well as labels requested in Question 4 F. EBAA Accreditation Board, Pre-inspection Questionnare June 2016 Page 3 of 4
B1.200 8. Please provide confirmation that if the eye bank was inspected by an official agency and received any written documentation of observations, findings or results (including, but not limited to, FDA Form 483) that a copy was sent to the EBAA Office within ten (10) business days of receipt. 9. Send a copy of the completed questionnaire, accompanying documentation, and Declaration of Compliance with Governmental Regulations to both inspectors assigned to your bank. It should be sent with the copy of your Policy & Procedure Manual to arrive 20 working days before the scheduled date of your inspection. Please have all individuals who assisted in the completion of the questionnaire sign in the spaces provided below. In addition, the Director should sign in the designated space to verify his/her approval and the accuracy of the contents. Director Date NOTE: THIS COMPLETED QUESTIONNAIRE, ACCOMPANYING DOCUMENTATION, DECLARATION OF COMPLIANCE WITH GOVERNMENTAL REGULATIONS AND YOUR POLICY & PROCEDURE MANUAL SHOULD BE MAILED DIRECTLY TO YOUR TWO ASSIGNED SITE INSPECTORS FOR ARRIVAL NO LATER THAN TWENTY (20) WORKING DAYS PRIOR TO THE SCHEDULED DATE OF INSPECTION. EBAA Accreditation Board, Pre-inspection Questionnare June 2016 Page 4 of 4
QUESTION #1: INFORMATION ON AGENCIES WHICH PROVIDE SERVICES TO THE EYE BANK. QUESTION #1-A: SEROLOGY (Please provide this information whether testing is done by the eye bank or by an outside lab.) Provide Copies of Documentation of each year of Accred., Certif. (CLIA/FDA), etc. for each lab since last inspection. NAME OF SEROLOGY LAB DATES LAB PROVIDED SERVICES ACCRED. AND/OR REG. AGENCIES TESTS PERFORMED METHODOLOGIES USED VALIDATION OR CONTROL PROCEDURES/FREQUENCY EBAA Accreditation, Pre-Inspection Questionnaire Worksheet - Revised June 2016 Page 1 of 5
QUESTION #1-B: ALL OTHER SERVICES (Please provide information for all agencies, including the eye bank, which provide services; i.e., instrument sterilization, biohazardous waste disposal according to state and federal regulations; eye banking functions provided by another eye bank or entity) Provide Copies of Documentation of each year of Accred., Certif. (CLIA/FDA), etc. for each agency since last inspection. NAME OF AGENCY DATES AGENCY PROVIDED SERVICES TYPE OF SERVICE ACCREDITING AND/OR REGULATORY AGENCIES VALIDATION OR CONTROL PROCEDURES AND FREQUENCY (if applicable) EBAA Accreditation, Pre-Inspection Questionnaire Worksheet - Revised June 2016 Page 2 of 5
QUESTION #1-C: NAME OF NON- EMPLOYEE RECOVERY, PRESERVATION, AND/OR PROCESSING SERVICES (Please complete the requested information below AND submit documentation to confirm the training, certification, and annual review of any non-employees that recover or process ocular tissue on behalf of your eye bank for each year since your last inspection. Also include any applicable licensure or accreditation documentation of the non-employee's employer for each year since last inspection.) DATES NON- EMPLOYEE PROVIDED SERVICES TYPE OF SERVICE(S) PROVIDED NON-EMPLOYEE'S EMPLOYER ACCREDITING AND/OR REGULATORY AGENCIES EBAA Accreditation, Pre-Inspection Questionnaire Worksheet - Revised Jund 2016 Page 3 of 5
QUESTION #2: STAFF Please list the names of all staff authorized by the eye bank to perform identified functions. Indicate employment status (e.g., full time, part time, on call) and relevant certifications and or degrees and whether or not the person is a Medical Director designee. MED DIR DONOR HISTORIES RECOVERY/PROCESSING SLIT LAMP EMPLOY CERTIF./ DESIGNEE SCREEN DETERMINE IN SITU ENUCLE- C-S DISC EK DMEK OTHER WHOLE NAME STATUS DEGREE Y / N DONOR SUITABILITY EXCISION ATION IN LAB PROC PROC PROC EYE CORNEA SPEC. EBAA Accreditation, Pre-Inspection Questionnaire Worksheet - Revised June 2016 Page 4 of 5
QUESTION #2: CONTINUED MED DIR DONOR HISTORIES RECOVERY/PROCESSING SLIT LAMP EMPLOY CERTIF./ DESIGNEE SCREEN DETERMINE IN SITU ENUCLE- C-S DISC EK DMEK OTHER WHOLE NAME STATUS DEGREE Y / N DONOR SUITABILITY EXCISION ATION IN LAB PROC PROC PROC EYE CORNEA SPEC. EBAA Accreditation, Pre-Inspection Questionnaire Worksheet - Revised June 2016 Page 5 of 5